Medical staff credentialing — primary-source verification of sanctions and exclusions
Template version 2026-10-06 — adopted by: ____________________  effective: __________  owner: Director, Medical Staff Services (owner); Credentials Committee (decision); Compliance Officer (oversight)

Template. Written against the public text of the standard cited; the organization adopts, edits and owns it as its protocol. Every threshold, identity, hold or disclosure decision belongs to the organization. We report the findings against the protocol — counts, dates, states — nothing more. Not legal advice, not a compliance determination, not a consumer report.

STANDARDS SERVED
- 42 CFR 482.22 — Conditions of Participation: medical staff; credentialing and privileging — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/section-482.22
- The Joint Commission MS.06.01.03 / MS.06.01.05 — primary source verification; reappointment at least every 2 years (verify current edition) — https://www.jointcommission.org/
- NCQA Credentialing standards CR 1 / CR 3 — sanctions verified from an acceptable source within the time frame; recredentialing within 36 months — https://www.ncqa.org/programs/health-plans/credentialing/
- HHS-OIG LEIE — the primary source for federal program exclusion — https://oig.hhs.gov/exclusions/

SCOPE
Every applicant for appointment or reappointment, every privileged practitioner and allied health professional, and telemedicine practitioners credentialed by proxy.

FREQUENCY
At initial appointment and reappointment, within the time frame the accreditor sets before the committee decision; monthly between cycles under HOSP-01.

PROCEDURE
1. Collect the identifiers that make a match exact: NPI, state license number(s), DEA number where applicable, DOB. A name alone yields candidates, not a verification.
2. Within the accreditor's window before the Credentials Committee date: one dated read of OIG LEIE and the state Medicaid exclusion list(s) by NPI and exact name; SAM.gov exclusions; state licensing board action records for each license held; DEA registrant actions where published. The record must show the source, the source's own date and the date verified.
3. File the record in the credentials file as the primary-source verification of sanctions. The record is a read of the source itself, not a report about the source — note that for the surveyor.
4. Any row printed under the practitioner's exact name or NPI goes to the Medical Staff Director for identity confirmation against the agency record, then to the Committee with the identity decision documented.
5. A source that did not answer is re-read before the Committee date; if it cannot be, the file states which source was not verified and the Committee decides under its bylaws.
6. Between cycles, the practitioner stays on the monthly roster (HOSP-01). Reappointment restarts this procedure.

MEASURES (findings reported monthly; the threshold for each is your protocol's)
- Verification within window: files whose sanctions read is dated inside the accreditor's pre-decision window ÷ files decided. Data: credentials file dates; receipt created_at. Threshold: your protocol: ________
- Exact-key verification rate: files verified by NPI (and license number) rather than name only ÷ files. Data: receipt identity block. Threshold: your protocol: ________
- Reappointment timeliness: practitioners reappointed within 24 months (TJC) / recredentialed within 36 months (NCQA) ÷ due. Data: MSO database. Threshold: your protocol: ________
- Source completeness at decision: files with every sanctions source answered on the decision date ÷ files. Data: receipt did_not_answer. Threshold: your protocol: ________
- Survey producibility: minutes to produce the dated sanctions verification for a surveyor-selected file. Data: HOSP-08 drill. Threshold: your protocol: ________

RECORDS
- Credentials file with dated sanctions read (source, source date, verify date, hash) — kept by MSO — retention per medical staff bylaws and HOSP-08
- Identity decisions on candidate rows — kept by Medical Staff Director — retention with the file

WHAT THIS PROCEDURE DOES NOT DECIDE
Appointment, privileges, identity of same-name rows, and any adverse action — those are the Credentials Committee's and the Board's under the bylaws and due-process rules.

CHANGE LOG (add a line for every change; keep superseded versions)
- 2026-10-06: First issue.
- ________: adopted/edited by ____________________

Source template: https://alphacovenantholdings.com/api/public-record/sop-templates/hosp-03-credentialing-sanctions/html · Duty Sheets: https://alphacovenantholdings.com/api/public-record/duty-sheets · Our own procedures: https://alphacovenantholdings.com/api/trust/sops